Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain

Abstract

Abstract-Based on the available evidence, the Therapeutics and Technology Assessment subcommittee concluded that 1) epidural steroid injections may result in some improvement in radicular lumbosacral pain when assessed between 2 and 6 weeks following the injection, compared to control treatments (Level C, Class I-III evidence). The average magnitude of effect is small and generalizability of the observation is limited by the small number of studies, highly selected patient populations, few techniques and doses, and variable comparison treatments; 2) in general, epidural steroid injection for radicular lumbosacral pain does not impact average impairment of function, need for surgery, or provide long-term pain relief beyond 3 months. Their routine use for these indications is not recommended (Level B, Class I-III evidence); 3) there is insufficient evidence to make any recommendation for the use of epidural steroid injections to treat radicular cervical pain (Level U). NEUROLOGY 2007;68:723-729 Chronic back pain and its associated disabilities represent an important health problem. 1 The rising prevalence of obesity may increase the impact of chronic back pain. The competitive nature of the modern workplace places individuals with less than perfect health and, in particular, those with painful conditions at a disadvantage. Workplace accommodation may not be an option for many occupations and, even where possible, is frequently linked with economic losses for employee and employer alike.In 1998, individuals with back pain in the United States were estimated to have incurred total health care expenditures of $90.7 billion.2 Inpatient care accounted for 31% of the expenditure, followed by expenditure for office-based visits (26%), prescription drugs (15.6%), and outpatient services (13.1%). Emergency department visits and home health visits each accounted for 3%. Of the $90.7 billion total expenditures incurred by these individuals, the expenditures attributable directly to the back pain totaled approximately $26.3 billion, 2 of which 42% were for office-based visits, 18% for outpatient services, 17% for inpatient care, 15% for prescription drugs, and 4% for emergency room visits. The estimated cost of treatments for spinal pain (medical therapy, epidural steroid injections, spinal cord stimulation, and intrathecal narcotics) for 1990 was at least $13 billion, growing by 7% per year.3 Medicare part B claims in 1999 for 40.4 million covered individuals were $49.9 million for lumbar epidural steroid injections, $8.5 million for lumbar facet or peri-facet joint injections, and $5.6 million for cervical or thoracic epidural steroid injections. 4 Low back pain may occur without or with radicular features (the latter often referred to as sciatica). In the strictest sense, sciatica refers to pain running down the posterior aspect of the lower extremity. A less restrictive usage to refer to lower back pain with

Time-dependent effect of epidural steroid on pain behavior induced by chronic compression of dorsal root ganglion in rats

“…Therefore, the current animal data should not be readily extrapolated into clinical situations. However, these animal data may provide some insight into the debate over the effectiveness of epidural steroid injection on chronic pain management (Armon et al, 2007). Our data may also shed light on the variation regarding the clinical outcome of epidural steroid treatment for radicular pain, suggesting that the timing of steroid treatment could be considered as an important factor in clinical settings.…”

“…Epidural steroid injection has been commonly used as a non-surgical treatment for radicular pain (Bogduk et al, 1994;Goebert et al, 1961). While a number of open-label clinical studies have shown the beneficial effects of epidural steroid injection (e.g., Spaccarelli et al, 1996), several prospective, randomized, controlled studies have failed to provide convincing evidence for its clinical efficacy (Armon et al, 2007;Carette et al, 1997;Arden et al, 2005;Price et al, 2005;Valat et al, 2003). To date, it remains unclear with regard to the clinical efficacy of epidural steroid injection for the treatment of radicular pain (Armon et al, 2007).…”

Degenerative lumbar stenosis: update

“…Their effect is attributed to decreasing the inflammation between the nerve root and the elements compressing it. Some patients have a temporary control (weeks to months) of symptoms after having these injections 24 . despite some controversy associated with the real efficacy of these injections, they are being used at increased frequency around the world and being promoted as a form of safe and minimally invasive treatment 25 .…”

Interventional pain medicine: retreat from the biopsychosocial model of pain

“…There has been longstanding and continued controversy surrounding the efficacy of IPM for the long-term management of chronic pain [21,22]. Numerous critical reviews have failed to find evidenced-based support for the routine use of IPM [10,[21][22][23] as well as for specific procedures such as epidural steroid injections [24][25][26][27] and facet blocks [28,29] for the management of chronic spinal pain. Routine administration of nerve blocks for chronic pain is further challenged by studies of healthy and clinical populations that find little association between abnormalities on magnetic resonance imaging or computerized tomography, upon which much of the decisionmaking for IPM relies, and pain experience [30][31][32][33].…”